ROSE LINN CARE CENTER

2330 DEBOK ROAD, WEST LINN, OR 97068 (503) 655-0474
For profit - Limited Liability company 71 Beds Independent Data: November 2025
Trust Grade
75/100
#28 of 127 in OR
Share this report: Email Text Facebook WhatsApp
Last Inspection: January 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Rose Linn Care Center in West Linn, Oregon, has a Trust Grade of B, indicating it is a good choice for families, generally performing better than average. It ranks #28 out of 127 facilities in the state, placing it in the top half, and #4 out of 13 in Clackamas County, meaning only three local options are better. The facility's situation is stable, with consistent issues reported over the past two years. Staffing is average with a rating of 3 out of 5 stars; turnover is relatively low at 33%, which is better than the state average of 49%, but there is concerning RN coverage, falling below 98% of state facilities. While there have been no fines, there have been serious incidents, including a resident being sent to the hospital for a significant laceration after a staff member failed to follow the care plan requiring a two-person assist for transfers. Additionally, staffing shortages have impacted medication administration and restorative care programs, highlighting some weaknesses alongside the facility's overall strengths.

Trust Score
B
75/100
In Oregon
#28/127
Top 22%
Safety Record
Moderate
Needs review
Inspections
Holding Steady
1 → 1 violations
Staff Stability
○ Average
33% turnover. Near Oregon's 48% average. Typical for the industry.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Oregon facilities.
Skilled Nurses
⚠ Watch
Each resident gets only 11 minutes of Registered Nurse (RN) attention daily — below average for Oregon. Fewer RN minutes means fewer trained eyes watching for problems.
Violations
⚠ Watch
17 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★★★
5.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★★
5.0
Inspection Score
↔
Stable
2024: 1 issues
2025: 1 issues

The Good

  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record
  • Staff turnover below average (33%)

    15 points below Oregon average of 48%

Facility shows strength in fire safety.

The Bad

Staff Turnover: 33%

13pts below Oregon avg (46%)

Typical for the industry

The Ugly 17 deficiencies on record

2 actual harm
Jan 2025 1 deficiency
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0582 (Tag F0582)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to ensure residents were provided accurate information and informed in writing of advanced beneficiary information for 2 of 2...

Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure residents were provided accurate information and informed in writing of advanced beneficiary information for 2 of 2 sampled residents (#s 114 and 115) reviewed for required beneficiary notification. This placed residents at risk for not being informed of financial liabilities and the right to an appeal. Findings include: Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) indicated notices are valid when all patient specific information required by the notice is included. 1. Resident 114 was admitted to the facility in 9/2024 with diagnoses including diabetes and schizophrenia (mental health disorder). Resident 114's clinical record indicated the resident had Medicare Part A coverage. Resident 114's Profile indicated her/his financial and care POA (Power of Attorney) was Witness 3 (Family). A 9/25/24 facility email was sent to Witness 3 by Staff 9 (Former Social Services Director) that indicated Resident 114 was provided a Notice of Medicare Non-Coverage (NOMNC) form. The NOMNC form contained no information related to Resident 114's effective date of coverage, a date when coverage was to end or the contact information for the Quality Improvement Organization to request an appeal. A 9/28/24 Discharge Summary indicated Resident 114 was ready to discharge to her/his home with outpatient supervision. A 9/30/24 Social Services Note indicated Witness 3 did not sign and return Resident 114's NOMNC form. On 1/29/25 at 12:54 PM Staff 4 (Social Services Director) acknowledged Resident 114's NOMNC form was not valid due to incomplete information on the form. 2. Resident 115 was admitted to the facility in 11/2024 with diagnoses including dementia and a thoracic vertebrae (spine) fracture. Resident 115's clinical record indicated the resident had Medicare Part A coverage. A 12/17/24 Discharge Summary indicated Resident 115 completed her/his therapy services and was cleared to discharge. Review of Resident 115's clinical record revealed no Notice of Medicare Non-Coverage (NOMNC) form was provided to the resident. On 1/29/25 at 12:54 PM Staff 4 (Social Services Director) confirmed a NOMNC form was needed for Resident 115 and was not provided.
Jun 2024 1 deficiency
CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to follow the resident's plan of care to prevent a fall for 1 of 1 sampled resident (#1) reviewed for falls. This placed resi...

Read full inspector narrative →
Based on interview and record review it was determined the facility failed to follow the resident's plan of care to prevent a fall for 1 of 1 sampled resident (#1) reviewed for falls. This placed residents at risk for falls with injury. Findings include: Resident 1 admitted to the facility in 2021 with diagnoses including dementia. The 8/16/23 revised Care Plan indicated Resident 1 was at risk for falls related to cognitive impairment and required assistance with mobility. Interventions included the use of a Hoyer (mechanical lift) for transfers. The Care Plan also indicated Resident 1 was resistant to care with interventions including to use a calm tone/approach and to not rush during care. A 9/28/23 facility fall investigation indicated Staff 5 (CNA) transferred Resident 1 using a Sara lift (sit to stand transfer device) when the resident's foot slipped and the resident lost her/his balance. The resident hit her/his mouth and sustained a cut on the lower lip with bruising. Resident 1 was care planned for a two-person transfer using a hoyer lift. Staff 5 did not follow the Care Plan and used a Sara lift instead of the Hoyer to transfer the resident. On 6/18/24 at 10:12 AM Staff 5 stated she was familiar with Resident 1. Staff 5 stated on the day of the incident, Resident 1 was to suppose to receive a shower. Staff 5 stated she was scared to use the Hoyer sling on Resident 1 due to her/his aggression when she/he was placed on the sling. Staff 5 further stated stated the facility was out of Hoyer slings at the time and instead of getting three or four staff to assist with transferring Resident 1, she decided to use the sit to stand to transfer the resident. Staff 5 stated Resident 1 did not fall but was guided to the floor. Staff 5 stated Staff 6 (LPN) was present during the entire incident. Staff 5 acknowledged Resident 1 was care planned for two-person assistance with a Hoyer for transfers. On 6/18/24 at 10:27 AM Staff 2 (RNCM) stated she was asked to look at Resident 1 after the fall. Staff 2 stated Resident 1 had a history of being resistant to care if she/he was not approached in a calm manner, and required a two person transfer. Staff 2 stated she asked Staff 5 if she used the sit to stand to transfer Resident 1 and Staff 5 indicated she did. Staff 2 stated she was informed by Staff 5 that Staff 5 transferred Resident 1 by herself. On 6/18/24 at 10:50 AM Staff 3 (CMA) stated she was next door in the medication room when Staff 5 asked for assistance with Resident 1. Staff 3 stated she and Staff 6 went into the room, and Resident 1's feet were off the sit to stand with her/his face leaning on part of the device. Staff 3 stated Staff 3 was present in the room when Staff 5 was told she was not suppose to use the sit to stand to transfer Resident 1, and was not suppose to transfer the resident alone. On 6/18/24 at 11:22 AM Staff 6 stated she was not in the room during Resident 1's fall and did not enter the room until Staff 5 yelled for assistance. Staff 6 stated Staff 5 tried to tell staff she was in the room with her but she was not. Staff 6 stated when she entered the room with Staff 5, the resident's lip was resting against the bar of the sit to stand. Staff 6 further stated Staff 5 was aware she was not supposed to use the sit to stand to transfer Resident 1. On 6/18/24 at 9:30 AM and 12:05 PM Staff 1 (Administrator) stated Staff 5 was terminated as a result of the incident on 9/28/23. Staff 1 acknowledged Staff 5 did not follow the care plan, resulting in Resident 1's fall.
Sept 2023 3 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0685 (Tag F0685)

Could have caused harm · This affected 1 resident

2. Resident 39 admitted to the facility in 12/2022 with diagnoses including depression and anxiety. A 7/20/23 Quarterly MDS revealed Resident 39 was moderately cognitively impaired. A Hearing Health ...

Read full inspector narrative →
2. Resident 39 admitted to the facility in 12/2022 with diagnoses including depression and anxiety. A 7/20/23 Quarterly MDS revealed Resident 39 was moderately cognitively impaired. A Hearing Health Progress note dated 7/27/23 revealed Resident 39 needed an appointment with an ENT (Ear, Nose and Throat) specialist to have her/his ears cleaned. A review of Resident 39's medical record revealed no evidence an ENT appointment was scheduled. On 9/7/23 at 1:53 PM Staff 2 (DNS) and Staff 4 (RN) confirmed an ENT appointment was not made for Resident 39 to get her/his ears cleaned. Based on interview and record review it was determined the facility failed to ensure treatment and services to maintain hearing abilities were provided for 2 of 2 sampled resident (#s 22 and 39) reviewed for hearing. This placed residents at risk for communication barriers and impaired hearing. Findings include: 1. Resident 22 admitted to the facility in 12/2022 with diagnoses including dementia and depression. Social Service Hearing and Vision Summaries revealed the following: -2/28/23: Resident 22 had difficulty hearing a speaker at conversational volume when there was background noise but could hear well once background noise was eliminated. Resident 22 was not seen for an audiology appointment since her/his admission. The resident and Witness 1 (Family Member) requested Resident 22 be seen because the resident had hearing aids in the past. Social Services was to schedule an appointment. -5/15/23 and 8/1/23: Resident 22 was in the process to receive hearing aids through an audiology appointment per the resident and Witness 1's request. A 7/27/23 Quarterly MDS revealed Resident 22 had severe cognitive impairment. A 9/5/23 Progress Note revealed Staff 3 (RNCM) spoke with Witness 1 and an audiology appointment was scheduled in 5/2023 but was canceled and a new audiology appointment was made. On 9/5/23 at 11:18 AM Witness 1 stated she requested a hearing aid test to be completed for Resident 22 because she/he was hard of hearing and could not participate in conversations when Witness 1 visited. Witness 1 indicated the facility did not initiate an appointment and Resident 22 was still without hearing aids. Witness 1 further stated this was frustrating and very important because it was difficult for Resident 22 to understand and participate in conversations. On 9/6/23 at 12:45 PM Staff 3 stated he was new to his position and scheduled an audiology appointment for Resident 22 but was unaware this was an issue prior to his conversation with Witness 1 on 9/5/23. On 9/7/23 at 1:46 PM Staff 2 (DNS) and Staff 4 (RN) acknowledged Resident 22 did not have an audiology appointment scheduled timely. Staff 2 and Staff 4 stated staff were expected to communicate to Staff 8 (Social Service Director) to follow up and ensure appointments were made timely. Staff 4 stated Staff 8 was new to her position (two weeks).
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 1 of 5 sampled residents (#6) reviewed for unnecessary...

Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure pharmacy recommendations were addressed by the physician for 1 of 5 sampled residents (#6) reviewed for unnecessary medications. This placed residents at risk for medication complications and side effects. Findings include: Resident 6 admitted to the facility in 12/2022 with diagnoses including chronic heart failure and atrial fibrillation (an irregular, often rapid heart rate). A physician order dated 12/19/22 directed staff to administer digoxin (a cardiac stimulant [can cause many adverse side effects, is involved in multiple drug interactions, and can result in toxicity]) one time a day for chronic heart failure. A Pharmacy Recommendation dated 7/1/23 indicated the facility to consider drawing digoxin level because no digoxin level was on file since admission in 12/2022. On 9/7/23 at 11:45 AM Staff 7 (Pharmacy Consultant) stated she completed monthly pharmacy reviews for Resident 6 and requested a digoxin level in 7/2023 but it was not completed. Staff 7 stated she could not locate a digoxin level and would expect the facility to monitor Resident 6's digoxin level to ensure Resident 6 was stable on her/his current digoxin medication. On 9/8/23 at 9:27 AM Staff 2 (DNS), Staff 4 (RN) and Staff 3 (RNCM) acknowledged the 7/1/23 pharmacy recommendation was not followed up on timely and they could not locate any documentation to verify Resident 6 had a base line digoxin level completed.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0887 (Tag F0887)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to ensure the resident's medical record included documentation of the resident's COVID-19 vaccination status for 1 of 5 sampl...

Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure the resident's medical record included documentation of the resident's COVID-19 vaccination status for 1 of 5 sampled residents (#39) reviewed for COVID-19 vaccine immunization. This placed residents at risk for the COVID-19 virus. Findings include: Resident 39 admitted to the facility in 12/2022 with diagnoses including depression and anxiety. A 7/20/23 Quarterly MDS revealed Resident 39 was moderately cognitively impaired. A review of Resident 39's medical record revealed no information regarding her/his COVID-19 vaccination status. On 9/7/23 at 1:52 PM and 9/8/23 at 9:03 AM Staff 2 (DNS) and Staff 4 (RN) confirmed there was no documentation regarding Resident 39's COVID-19 vaccination status.
Aug 2022 12 deficiencies 2 Harm
SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Deficiency F0658 (Tag F0658)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure Staff 17 (Former Agency CNA) adhered to pro...

Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to ensure Staff 17 (Former Agency CNA) adhered to professional standards of practice regarding Staff 17 not following Resident 1's care plan of a two-person assist for transfers. This resulted in Resident 1 sustaining a deep laceration on her/his left knee that required sutures. This placed residents at risk for accidents. Findings include: Resident 1 was admitted in 2015 with diagnoses including dementia. The resident's comprehensive care plan dated 9/17/15 revealed Resident 1 was a two-person assist with all transfers. The Quarterly MDS dated [DATE] indicated Resident 1 was severly cognitively impaired. The 4/7/22 progress note revealed Resident 1 sustained a deep laceration with profuse bleeding across her/his left kneecap during a transfer from bed to wheelchair caused by Staff 17 not following the care plan which included a two-person assist with all transfers. As a result, Resident 1 was sent to the hospital emergency department for sutures. The 4/7/22 hospital emergency department discharge summary revealed Resident 1 had a 6 cm (2.3 inches) laceration just below the left kneecap. As a result, the wound was repaired with twelve sutures. On 7/27/22 at 10:54 AM, Staff 2 (DNS) confirmed Resident 1 required a two-person assist for all transfers. Staff 2 stated Staff 17 had completed orientation on Resident 1's unit which included the facility's policy and responsibilities related to resident care plans. Staff 2 stated Staff 17 was oriented to use the [NAME] (system of communication) for resident care plans and Staff 17 was familiar with this system as he had worked at this facility three times. Staff 2 stated Staff 17 should have requested assistance for transferring Resident 1 to her/his wheelchair. On 7/28/22 at 6:28 PM, Staff 17 stated the injury sustained by Resident 1 was his fault and it was an unfortunate mistake. Staff 17 stated Resident 1 was a two-person assist for transfers, he did not follow the care plan and he did not ask for another person to assist with the transfer.
SERIOUS (G)

Actual Harm - a resident was hurt due to facility failures

Accident Prevention (Tag F0689)

A resident was harmed · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review it was determined the facility failed to ensure adequate transfer supervision to prevent i...

Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review it was determined the facility failed to ensure adequate transfer supervision to prevent injury for 1 of 2 residents (#1) reviewed for accidents. This failure resulted in Resident 1 sustaining a deep laceration with profuse bleeding across her/his left kneecap and required sutures at the hospital emergency department. Findings include: Resident 1 was admitted in 2015 with diagnoses including dementia. The resident's comprehensive care plan dated 9/17/15 revealed Resident 1 was a two-person assist with all transfers. The Quarterly MDS dated [DATE] indicated Resident 1 was severely cognitively impaired. The 4/7/22 progress note revealed Resident 1 sustained a deep laceration with profuse bleeding across her/his left kneecap during a transfer from bed to wheelchair caused by Staff 17 (Former Agency CNA) not following the care plan which included a two-person assist with all transfers. As a result, Resident 1 was sent to the hospital emergency department for sutures. The 4/7/22 hospital emergency department discharge summary revealed Resident 1 had a 6 cm (2.3 inches) laceration just below the left kneecap. As a result, the wound was repaired with twelve sutures. On 7/27/22 at 10:54 AM, Staff 2 (DNS) confirmed Resident 1 required a two-person assist for all transfers. Staff 2 stated Staff 17 had completed orientation on Resident 1's unit which included the facility's policy and responsibilities related to resident care plans. Staff 2 stated Staff 17 was oriented to use the [NAME] (system of communication) for resident care plans and Staff 17 was familiar with this system as he had worked at this facility three times. Staff 2 stated Staff 17 should have requested assistance for transferring Resident 1 to her/his wheelchair. On 7/28/22 at 6:28 PM, Staff 17 stated the injury sustained by Resident 1 was his fault and it was an unfortunate mistake. Staff 17 stated Resident 1 was a two-person assist for transfers, he did not follow the care plan, and did not ask for another person to assist with the transfer.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0558 (Tag F0558)

Could have caused harm · This affected 1 resident

Based on observation, interview and record review it was determined the facility failed to ensure a resident's environment accommodated the individual needs and preferences for 1 of 2 sampled resident...

Read full inspector narrative →
Based on observation, interview and record review it was determined the facility failed to ensure a resident's environment accommodated the individual needs and preferences for 1 of 2 sampled residents (#22) reviewed for restorative therapy. This placed residents at risk for skin breakdown. Findings include: Resident 22 was admitted to the facility in 3/2020 with diagnoses including stroke. The 6/2/22 progress note indicated Resident 22 stated she/he needed a new mattress due to the mattress being sunk in. On 7/26/22 at 10:54 AM Resident 22 stated she/he wanted a new mattress due to the mattress being indented. On 7/26/22 at 10:54 AM Resident 22's mattress was observed to have a large indentation in the middle of the mattress. On 7/28/22 at 11:55 AM Staff 8 (RNCM) stated she was unaware of Resident 22's request for a new mattress as staff did not report it to her. Staff 8 acknowledged the progress note on 6/2/22 indicated the request for a new mattress and no follow up was completed. Staff 8 observed Resident 22's mattress and acknowledged it was visibly sunken in.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Safe Environment (Tag F0584)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to ensure a clean and sanitary environment for 1 of 2 h...

Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview it was determined the facility failed to ensure a clean and sanitary environment for 1 of 2 halls. This placed residents at risk for cross contamination. Findings include: 1. On 7/26/22 at 12:50 PM room [ROOM NUMBER] was observed to have garbage on the floor. On 8/1/22 at 10:30 AM room [ROOM NUMBER] floor was observed to be sticky with garbage and crumbs of food on the floor and under the bed including popcorn. Resident 28 stated the room had not been cleaned for a week. On 8/1/22 at 10:34 AM Staff 4 (Housekeeping Supervisor) stated room [ROOM NUMBER] was one of our worst rooms. Staff 4 acknowledged the floor was sticky with garbage and crumbs of food under the bed including popcorn. 2. On 7/26/22 at 12:02 PM and 8/1/22 at 10:36 AM room [ROOM NUMBER] was observed to have a wall next to a resident's bed with several brown smudges on it. On 8/1/22 at 10:36 AM Staff 4 (Housekeeping Supervisor) acknowledged the brown smudges on the wall next to the resident's bed. Staff 4 attempted to remove the smudges with a cleaning wipe, some of the brown smudges were removed and she stated the rest were stains. On 8/1/22 at 10:46 AM Staff 26 (Maintenance Director) acknowledged the brown smudges on the wall and stated the wall was plastic and the smudges could be removed by deep cleaning the wall.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (# 28) reviewed for medication. This placed residents at risk for a c...

Read full inspector narrative →
Based on interview and record review it was determined the facility failed to follow physician orders for 1 of 5 sampled residents (# 28) reviewed for medication. This placed residents at risk for a change in condition. Findings include: Resident 28 admitted to the facility in 2021 with diagnoses including chronic obstructive pulmonary disease (COPD). The 7/11/22 physician orders indicated Resident 28 was to receive daily weights and to notify the physician if the resident gained two pounds in two days or five pounds or more in a week. The 7/2022 TARS and weight records indicated the following weights for Resident 28: -7/16/22: 220 pounds; -7/17/22: 224.6 pounds (4.6 pound weight gain); -7/18/22: 228 pounds (3.4 pound weight gain). There was no indication in the clinical record to indicate the physician was notified of the 4.6 pound weight gain on 7/17/22 or the 3.4 pound weight gain on 7/18/22. On 7/29/22 at 11:11 AM Staff 2 (DNS) acknowledged the physician was not notified of the 4.6 pound weight gain on 7/17/22 or the 3.4 pound weight gain on 7/18/22 and the physician orders were not followed.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0757 (Tag F0757)

Could have caused harm · This affected 1 resident

Based on interview and record review the facility failed to ensure residents were free from unnecessary medications for 1 of 5 sampled residents (#28) reviewed for medication. This placed residents at...

Read full inspector narrative →
Based on interview and record review the facility failed to ensure residents were free from unnecessary medications for 1 of 5 sampled residents (#28) reviewed for medication. This placed residents at risk for drug to drug interactions and adverse drug events. Findings include: Resident 28 admitted to the facility in 2021 with diagnoses including restless leg syndrome (RLS). The 6/6/22 physician order indicated Resident 28 was to receive ropinorole (antiparkinson agent and dopamine agonist medication used for RLS) 0.5 mg TID for RLS. The 7/7/22 progress note indicated Resident 28 complained of RLS and wanted treatment for relief. A request was sent to the physician to trial medication. A 7/7/22 fax from the physician indicated an order for Mirapex (antiparkinson agent and dopamine agonist medication used for RLS) 0.5 mg PO at bedtime. A 7/18/22 pharmacy recommendation note indicated Resident 28 received ropinorole 0.5 mg TID and Mirapex 0.5 mg QHS. The note indicated to evaluate the use of ropinorole plus Mirapex. The note further indicated the fax to the physician from nursing did not appear the preexisting order for ropinorole was acknowledged by nursing staff. On 7/18/22 the physician signed the recommendation and discontinued Mirapex. The 7/2022 MAR indicated Resident 28 received the following medication: -Mirapex at bedtime from 7/7/22 through 7/17/22; -ropinorole TID for the month of July. On 7/29/22 at 11:17 AM Staff 2 (DNS) acknowledged Resident 28 received both the ropinorole and Mirapex from 7/7/22 through 7/17/22. Staff 2 further acknowledged staff should have reviewed her/his medications prior to starting the Mirapex. Staff 2 acknowledged Resident 28 received medications with the same therapeutic and pharmacologic classifications resulting in duplicate therapy.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to have an appropriate indication for use of psychotr...

Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined the facility failed to have an appropriate indication for use of psychotropic medications for 1 of 5 sampled residents (#53) reviewed for medication. This placed residents at risk for receiving unnecessary medication and adverse side effects. Findings include: Resident 53 was admitted on [DATE] with diagnoses including anxiety disorder and depression. The 4/7/22 BIMS indicated Resident 15 was cognitively intact. A 5/3/22 physician note indicated Resident 15 had anxiety/depression disorder- severe, [she/he] has a component of depression ,will increase Lexapro [antidepressant medication] and add Zyprexa [antipsychotic medication] and see if this helps with overall mood. A review of the clinical record indicated no documented behaviors for 3/2022, 4/2022 and 5/2022. The 5/16/22 pharmacy recommendation indicated Resident 53 received an antipsychotic drug Zyprexa without a clear diagnosis in the chart. Centers for Medicare and Medicaid Services (CMS) guidelines require the following conditions to support the use of antipsychotics. Please update diagnosis for the above antipsychotic. (A list of diagnoses was provided and the physician circled the diagnosis of Behavioral or psychological symptoms of dementia (BPSD) (all antipsychotics carry a FDA Black Box Warning regarding the increased risk of death in elderly patients with dementia. On 7/28/22 at 8:46 AM Staff 23 (Activities Assistant) stated Resident 53 was alert and oriented and enjoyed 1:1 activities in her/his room. On 7/28/22 at 9:01 AM Staff 24 (LPN) stated Resident 53 was alert and oriented and her/his cognition had not changed since admission. On 7/28/22 at 9:11 AM Staff 25 (CMA/CNA) stated Resident 53 was pretty alert and able to make her/his needs known and was able to take her/himself to therapy daily. Staff 25 further stated Resident 53 was less anxious and more alert since admission. On 7/28/22 at 11:46 AM Staff 19 (Physical Therapist) was asked if Resident 53 was alert and oriented, Staff 19 stated yes [she/he] definitely is. Staff 19 stated the resident admitted in December 2021 and had some anxiety and depression but [Resident 53] is with it. Staff 19 further stated Resident 53 had made improvements in therapy and the plan was for her/him to discharge home. Staff 19 further stated her/his cognition had improved since admission and had no cognitive deficits. On 8/1/22 at 8:59 AM and 12:23 PM Staff 2 (DNS) acknowledged there were no documented behaviors for 3/2022, 4/2022 and 5/2022 for Resident 53. Staff 2 acknowledged there was no supporting documentation by the physician or facility staff to support the diagnosis of dementia and the use of Zyprexa.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0825 (Tag F0825)

Could have caused harm · This affected 1 resident

Based on interviews, and record review it was determined the facility failed to obtain therapy services for 1 of 2 sampled residents (#2) reviewed for accidents. This placed resident at risk for a dec...

Read full inspector narrative →
Based on interviews, and record review it was determined the facility failed to obtain therapy services for 1 of 2 sampled residents (#2) reviewed for accidents. This placed resident at risk for a decline in functional abilities and accidents. Findings include: Resident 2 was admitted to the facility 7/19/22 with diagnoses including Parkinson's Disease. The resident's care plan dated 7/19/22 revealed Resident 2 was at risk for falls due to impaired balance and mobility and a one person assist for all transfers. A 7/19/22 Nursing admission Assessment indicated Resident 2 had weakness in her/his legs, a history of falls and a request for physical therapy (PT) was to be completed. A 7/20/22 Nurses Note indicated Resident 2 had a fall in her/his bathroom due to self-transferring from her/his wheelchair to the toilet. A 7/20/22 Fall Assessment-Post Fall indicated as a result of Resident 2's fall, a PT evaluation would be requested. A 7/22/22 Social Service admission Assessment indicated Resident 2 had a goal to work with therapy to gain strength. On 7/22/22 a Brief Interview for Mental Status (BIMS) was conducted and revealed Resident 2 was cognitively intact. On 7/26/22 at 2:09 PM, Staff 3 (RN) confirmed Resident 2 had a fall in her/his bathroom. On 7/28/22 at 10:36 AM, Staff 19 (PT/acting rehab manager) stated Resident 2 had no order for a PT evaluation. On 7/28/22 at 2:57 PM, Resident 2 stated PT was not been offered to her/him and she/he expressed an interest in PT to gain strength. On 7/28/22 at 3:15 PM, Staff 18 (Social Services) confirmed Resident 2 expressed interest in PT but she did not make a recommendation. On 7/29/22 at 11:08 AM, Staff 21 (LPN, Resident Care Manager) acknowledged the 7/19/22 and 7/20/22 nurse's PT recommendations and confirmed Resident 2 did not have orders for a PT evaluation.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0578 (Tag F0578)

Could have caused harm · This affected multiple residents

Based on interview and record review, it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an advanced directive for 4 of 6 s...

Read full inspector narrative →
Based on interview and record review, it was determined the facility failed to develop and implement policies and procedures regarding residents' rights to formulate an advanced directive for 4 of 6 sampled residents (#s 20, 23, 33 and 48) reviewed for advanced directives. This placed residents at risk for not having their health care preferences honored. Findings include: Records reviewed for Residents 20, 23, 33 and 48 revealed no documentation of an advance directive or documentation to indicate the residents were informed of or provided written information concerning their right to formulate an advance directive. On 7/27/22 at 12:45 PM Staff 11 (Admissions Director) stated a POLST (Physician Orders for Life Sustaining Treatment) and advance directive were requested from residents prior to admission. Staff 11 stated if there is a POLST there is not typically an advance directive and if an advance directive were filled out it would be done by the charge nurse the day of admission. On 7/27/22 at 1:13 PM Staff 13 (RN) stated she does not offer the advance directives with new admissions, the Resident Care Managers would do the paperwork with the residents on the day of admission. On 7/27/22 at 1:14 PM Staff 8 (RNCM) stated the advanced directives are in the resident admission packet and she had not filled out an advanced directive with a resident since the pandemic. Staff 8 stated she put please see POLST on the top of the advance directive and she had not offered an advanced directive with residents or their representatives in over a year. On 7/27/22 at 1:32 PM Staff 2 (DNS) stated there was not a process for discussing advance directives with residents upon admission to the facility. Staff 2 stated the facility had not provided documentation or verify residents were notified of their right to formulate an advance directive. On 7/27/22 at 2:30 PM Staff 1 (Administrator) provided an undated advanced directive policy and procedure which stated it was the Resident Care Managers responsibility to discuss filling out an advanced directive with a new resident or their representative. Staff 1 stated it was his expectation that residents were presented with an advanced directive and informed upon admission.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0688 (Tag F0688)

Could have caused harm · This affected multiple residents

2. Resident 22 was admitted to the facility in 3/2020 with diagnoses including stroke and weakness. The 3/3/20 Care Plan indicated the resident had a history of stroke, left sided weakness and impaire...

Read full inspector narrative →
2. Resident 22 was admitted to the facility in 3/2020 with diagnoses including stroke and weakness. The 3/3/20 Care Plan indicated the resident had a history of stroke, left sided weakness and impaired mobility. The 3/3/22 Annual MDS Functional Rehabilitation Potential indicated the resident required assistance to maintain functional status. The 6/2/22 Quarterly MDS indicated Resident 22 was cognitively intact. On 7/26/22 at 10:37 AM Resident 22 stated she/he would like to receive restorative therapy but the RAs were not available to assist her/him due to them being pulled to the floor to work as CNAs. Resident 22 further stated she/he was unable to open her/his left hand independently or move her/his left leg and foot independently. On 7/28/22 at 12:04 PM Staff 8 (RNCM) stated there was not a current RA program due to staffing and the last time the facility had a restorative program was August of 2021. Staff 8 provided a list of 19 residents who required RA, including Resident 22 and acknowledged there was no current program in place to ensure the residents received RA. Based on interview and record review it was determined the facility failed to ensure residents received restorative aid (RA) therapy to prevent ADL decline for 2 of 3 sampled residents (#s 22 and 52) reviewed for RA and falls. This placed residents at risk for physical decline and a decrease in well-being. Findings include: 1. Resident 52 admitted to the facility in 2019 with diagnoses including dementia and history of falls. The Resident's 5/2/20 care plan, with revisions on 6/21/22, indicated she/he was on a restorative nursing program to maintain/improve functional status related to strengthening and ambulation skills. The 6/21/22 Assistive Devices Assessment indicated Resident 52 worked with Restorative Nursing with a goal to maintain current strength and ambulation ability. The Restorative program was currently on hold. On 7/29/22 at 1:00 PM Resident 52 stated she/he was not working with RA but it would be good for someone to work with her/him so she/he can walk. On 7/28/22 at 12:04 PM and 8/1/22 at 10:45 AM Staff 8 (RNCM) stated there was not a current RA program due to staffing and the last time the facility had a restorative program was August of 2021. Staff 8 provided a list of 19 residents who required RA, including resident 52 and acknowledged there was no current program in place to ensure the residents received RA.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0727 (Tag F0727)

Could have caused harm · This affected multiple residents

Based on interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours per day for 7 of 58 days reviewed for staffing. This placed residents at ri...

Read full inspector narrative →
Based on interview and record review it was determined the facility failed to ensure RN coverage for eight consecutive hours per day for 7 of 58 days reviewed for staffing. This placed residents at risk for lack of care. Findings include: Review of the Direct Care Staff Daily Reports from 6/1/22 through 7/28/22 revealed on 6/3/22, 6/17/22, 6/24/22, 7/1/22, 7/8/22, 7/15/22 and 7/22/22 there was no RN coverage for eight consecutive hours. On 8/1/22 at 9:55 AM Staff 2 (DNS) acknowledged the lack of RN coverage on the indicated dates.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0725 (Tag F0725)

Could have caused harm · This affected most or all residents

Based on interview and record review it was determined the facility failed to provide sufficient staffing to meet resident needs for 2 of 2 resident halls reviewed for staffing. This placed residents ...

Read full inspector narrative →
Based on interview and record review it was determined the facility failed to provide sufficient staffing to meet resident needs for 2 of 2 resident halls reviewed for staffing. This placed residents at risk for unmet needs. Findings include: Review of Direct Care Staff Daily Report from 6/1/22 through 7/28/22 revealed the facility failed to meet the state required minimum number of CNA staff for 35 of 58 days. The following interviews were completed by residents regarding staffing: 7/26/22 at 12:34 PM Resident 53 stated she/he has waited up to two hours for assistance from staff. Resident 53 stated she/he needed assistance with brief changes and getting back into bed. 7/26/22 at 12:45 PM Resident 20 stated staff took a long time to answer call lights. Resident 20 stated staff would ask what was needed and not return to assist her/him. 7/26/22 at 1:21 PM Resident 28 stated she/he waited up to an hour for the call light to be answered. 7/27/22 at 10:00 AM Resident 50 stated she/he had to wait what seemed like an hour for the call light to be answered. 7/27/22 at 10:40 AM Resident 5 stated the call light could take up to an hour to be answered. The following interviews were completed by staff regarding staffing: On 7/27/22 at 12:26 PM Staff 16 (CNA) stated staffing had been a struggle and at times it was overwhelming to complete her daily assignments. On 7/27/22 at 2:21 PM Staff 9 (CNA) stated residents did not always receive adequate care due to staffing shortages. Staff 9 stated she did not receive her breaks most days and only sat down during lunch time. Staff 9 stated that she was asked to stay late most days to help cover the following shift. Staff 9 also stated Sundays were the most challenging day for staffing needs and CMA's and charge nurses would have to assist with resident care. On 7/28/22 at 11:09 AM Staff 14 (CMA) stated the facility was understaffed most shifts. Staff 9 stated it was not uncommon for staff to do one-person transfers when a two-person transfers was indicated due to staffing shortages and not being able to wait for someone else to assist with the transfers. Staff 9 stated when asked, she would come in early or stay late to help out. Staff 9 stated Sundays were a struggle with the medication pass because the CNA's needed so much assistance with resident care. On 7/28/22 at 12:04 PM Staff 8 (RNCM) stated there was not a current RA program due to staffing and the last time the facility had a restorative program was August of 2021. Staff 8 provided a list of 19 residents who required RA and acknowledged there was no current program in place to ensure the residents received RA. On 7/29/22 at 7:28 AM Staff 24 (LPN) stated the facility was often short staffed. Nursing staff often had to care for up to six residents in addition to completing her nursing duties. On 7/29/22 at 9:19 AM Staff 15 (Staffing Coordinator/CNA) stated he attempted to staff to the daily requirements, but it had been a challenge with regular staff and agency staff calling off. Staff 15 stated he will cover CNA shifts when the requirements cannot be met and there are days the RCM's and the DNS have had to cover the floor to help out. On 7/29/22 at 1:36 PM Staff 2 (DNS) stated staffing had been a struggle with Sundays being the toughest day to cover. Staff 2 stated regular staff and agency staff call off and it was a struggle to find coverage. She stated the staffing coordinator, CMA's, RCM's and sometimes herself would cover as needed. Staff 2 stated the CMA's are not given sections but rather two to three resident's during their shift. Staff 2 stated staffing continued to be an ongoing struggle and they are actively trying to hire staff for several positions. Refer to F688.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No fines on record. Clean compliance history, better than most Oregon facilities.
  • • 33% turnover. Below Oregon's 48% average. Good staff retention means consistent care.
Concerns
  • • 17 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.

About This Facility

What is Rose Linn's CMS Rating?

CMS assigns ROSE LINN CARE CENTER an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Oregon, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.

How is Rose Linn Staffed?

CMS rates ROSE LINN CARE CENTER's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 33%, compared to the Oregon average of 46%. This relatively stable workforce can support continuity of care.

What Have Inspectors Found at Rose Linn?

State health inspectors documented 17 deficiencies at ROSE LINN CARE CENTER during 2022 to 2025. These included: 2 that caused actual resident harm and 15 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.

Who Owns and Operates Rose Linn?

ROSE LINN CARE CENTER is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 71 certified beds and approximately 64 residents (about 90% occupancy), it is a smaller facility located in WEST LINN, Oregon.

How Does Rose Linn Compare to Other Oregon Nursing Homes?

Compared to the 100 nursing homes in Oregon, ROSE LINN CARE CENTER's overall rating (5 stars) is above the state average of 3.0, staff turnover (33%) is significantly lower than the state average of 46%, and health inspection rating (5 stars) is much above the national benchmark.

What Should Families Ask When Visiting Rose Linn?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Rose Linn Safe?

Based on CMS inspection data, ROSE LINN CARE CENTER has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Oregon. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Rose Linn Stick Around?

ROSE LINN CARE CENTER has a staff turnover rate of 33%, which is about average for Oregon nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Rose Linn Ever Fined?

ROSE LINN CARE CENTER has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Rose Linn on Any Federal Watch List?

ROSE LINN CARE CENTER is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

ROSE LINN CARE CENTER

2330 DEBOK ROAD, WEST LINN, OR 97068 | (503) 655-0474

B
Trust Grade (75/100)
5.0
CMS Rating
17
Deficiencies

Strengths

  • Licensed facility

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025